Veloxis Transplant Support Bridge Program Enrollment Form

Bridge Program Enrollment
The ENVARSUS XR® Bridge Program (“Bridge Program”) provides ENVARSUS XR® at no cost for a limited period to eligible patients who have been prescribed ENVARSUS XR® for an FDA-approved indication and whose insurance coverage is delayed.
Patient Contact Information [required *]
First Name{{First Name}} *
Last Name {{Last Name}} *
Date of Birth Date of Birth * / MM / DD YYYY
Zip Code *
Email{{Email}}
Phone #{{Phone #}} *
Facility Contact or Facility Pharmacist Information
Facility Name{{Facility Name}} *
Facility Phone #{{Facility Phone #}}
Facility Fax #{{Factility Fax#}}
Facility Contact Name {{Factility Contact Name}} *
Facility Contact Phone # {{Factility Contact Phone #}} *
Facility Contact Email *
Facility Contact Fax #{{Facility Contact Fax #}} *
Prescriber Name {{Prescriber Name}} *
Prescriber NPI #{{Prescriber NPI #}} *
How many days of therapy does the patient have on hand?{{Days of therapy on hand}} *
Patient Insurance Information (check all that apply){{Patient Insurance Information}}

Patient Insurance Information (check all that apply){{Patient Insurance Information}} Commercial Insurance Government-funded Insurance (e.g., Medicare, Medicaid, or TRICARE) No Insurance (cash-paying patient)
Health Care Provider Certification/Agreement
By submitting this form, I certify the following statements. I, the patient’s healthcare provider, acknowledge that to the best of my knowledge the information provided is accurate and that my patient currently meets the Eligibility Criteria and understands and agrees to comply with the Terms and Conditions (as shown below) of the ENVARSUS XR® Bridge Program including the requirement that the patient be prescribed ENVARSUS XR® for an FDA-approved indication. If I become aware the patient may no longer meet the criteria for the program, I agree to notify ENVARSUS XR® Bridge Program. I have received written authorization from the above-named patient (or the patient’s legal representative) as required by applicable laws to disclose the patient’s personal information, medical information and insurance information to Veloxis Pharmaceuticals, Inc. (“Veloxis”) and its authorized employees, agents, and representatives (collectively “Authorized Representatives”). Patient (or from the patient’s legal representative) has consented to and directed disclosure of patient’s information to Authorized Representatives for the purpose of assessing whether the patient qualifies for the ENVARSUS XR® Bridge Program (in accordance with its terms) and to administer the ENVARSUS XR® Bridge Program. The patient (or the patient’s legal representative) has provided consent to be contacted, by Authorized Representatives, in relation to the patient’s access to ENVARSUS XR® using an autodialer or prerecorded voice at the telephone number provided on this form regarding the purposes described above and for other non-marketing purposes. ENVARSUS XR® is medically necessary for this patient. I agree that my Facility will not submit, or cause to be submitted, any claims for payment or reimbursement to any third-party payor, including any federal healthcare program, such as Medicare or Medicaid, for ENVARSUS XR® or other support that may be provided through the ENVARSUS XR® Bridge Program. I understand that prescribers are under no obligation to prescribe any Veloxis product to participate in ENVARSUS XR® Bridge Program and have not and will not receive any benefit from Veloxis for prescribing a Veloxis product. Veloxis may change, terminate, or suspend my participation in the program without prior notice.
Printed Name{{Printed Name}} *
Signature *

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Date{{Date}} Date{{Date}} * / MM / DD YYYY
Bridge Voucher Information
Eligibility Criteria

Patient is commercially or federally insured.
Patient is currently experiencing a delay in insurance coverage for ENVARSUS XR® (e.g., the patient is undergoing a prior authorization or appeal of a coverage denial) and such delay is anticipated to last for at least five (5) days.
Patient must have a valid 30-day prescription for ENVARSUS XR® from a licensed US healthcare provider. Patient is actively pursuing insurance coverage.
Patient is being treated for an FDA-approved indication.
Patient must be 18 years or older to participate in the Bridge Program. For patients who are 17 years of age, the patient’s parent or legal guardian must verify the enrollment criteria and obtain ENVARSUS XR® on behalf of the patient.
Patient is a resident of the United States and its territories including Puerto Rico.
Terms and Conditions

By participating in the Bridge Program, patient must be currently experiencing a delay in insurance coverage for ENVARSUS XR® (e.g., the patient is undergoing a prior authorization or appeal of a coverage denial) and such delay is anticipated to last for at least five (5) days.
This offer is non-transferable.
The Bridge Program is administered by Veloxis’s designated hub pharmacy. Patients’ eligibility for the Bridge Program is not conditioned on any use of Veloxis’s designated hub pharmacy for any prescription fills that occur outside the Bridge Program.
Patients must not submit any claim for reimbursement for product dispensed pursuant to the Bridge Program to any third-party payor, including Medicare, Medicaid, or any other federal or state health care program. Patients cannot apply the value of the free product received through the Bridge Program toward any government insurance benefit out-of-pocket spending calculations, such as Medicare Part D True Out-of-Pocket Costs (TrOOP). Additionally, pharmacists and prescribers cannot seek reimbursement for the product received through the Bridge Program from health insurance or any third party, including state or federally funded programs.
This Bridge Program cannot be combined with any other savings, free trial, or similar offer for the specified prescription. No substitutions are permitted.
The Bridge Program is not health insurance.
Offer good only in the U.S. and its territories including Puerto Rico; this offer is void where restricted or prohibited by law. This offer is not conditioned on any past, present, or future purchase, including refills, and no purchase is necessary. Patients have no obligation to continue to use ENVARSUS XR®.
Veloxis reserves the right to amend the eligibility criteria and/or rescind, revoke or amend this offer without notice.
Data related to use of the Bridge Program may be collected, analyzed, and shared with Authorized Representatives for market research and other purposes related to assessing Veloxis’s programs. Data shared with Veloxis will be aggregated and de-identified; it will be combined with data related to other co-pay card redemptions and will not identify you.
©2024 Veloxis Pharmaceuticals, Inc. US-ENV-2400020 v2.0 7/24
Veloxis and ENVARSUS XR® are registered trademarks of Veloxis Pharmaceuticals, Inc.
All other trademarks are property of their respective owners.
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Veloxis Transplant Support Bridge Program Enrollment Form

Bridge Program Enrollment

Patient Contact Information [required *]

Facility Contact or Facility Pharmacist Information

Bridge Voucher Information

Eligibility Criteria

Terms and Conditions